STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students

Size: px
Start display at page:

Download "STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students"

Transcription

1 STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam, be sure your provider s office completes pages 2, 3, and 4, including a review of the vaccinations recommended by the Centers for Disease Control for your travel destination(s). 3. You must ensure that the completed and fully signed Study Abroad Health Form (5 pages) is ed, faxed or dropped off at or mailed to Gonzaga Study Abroad office. ( Fax: ; Mailing: 502 E. Boone Ave AD 85, Spokane, WA ; Office Location: Hemmingson Center Rm 102.) The health form may be completed up to five months prior to departure, and must be received by the deadline given to you by your program advisor. 4. This form (5 pages) is required by GU and is in addition to any forms required by your program. This requirement cannot be waived and is a condition of full acceptance into the program. 5. Some programs will require a separate health clearance form due to program requirements and/or country-specific risks. Be sure to get any additional/program-specific forms completed before the physical. For Medical Providers Students who wish to study abroad must be cleared by a health care provider. When determining a student s clearance status, please include the following steps and considerations: 1. Discuss/review the student s health history from page 1, paying particular attention to medications that the student may need, any allergies the student may have, and all currently active health problems. Students may be cleared for participation with these conditions provided they are in compliance with, and stable on their medication. 2. Review the Centers for Disease Control vaccine recommendations for his/her travel destination(s) and determine what, if any immunizations the student may need and assist the student in getting these completed (administer, prescribe, refer, etc.). While the medical provider may recommend travel immunizations, it is the student s responsibility to obtain the necessary immunizations for study abroad. 3. Perform a thorough physical examination. Please document on page Please impress on the student that he/she needs to take a sufficient amount of medication to last for the duration of the program abroad, or verify that the medication is locally available and legal. 5. Assess the need for any continued health care, counseling or laboratory testing while abroad so the student can determine the availability of adequate facilities at the program site. 6. Determine the student s level of health and fitness of undertaking participation on a study abroad program and initial health clearance status where indicated on page 4. Students may be cleared for participation as long as, in the opinion of the examining provider, any condition the student may have is under control and has been stable for a reasonable period.

2 For Office Use Only: Date: Received by: Program: Term: Scanned: Uploaded: STUDY ABROAD HEALTH FORM MEDICAL SELF-DISCLOSURE: COMPLETED BY STUDENT Last Name: First Name and Middle Initial DOB (MM-DD-YY): Zag ID#: Gender: F M Other: Permanent Address: Street City, State, and Zip Phone ( ) Person(s) to be notified in case of emergency: Name: Relationship: Address : Phone Hm ( ) Wk ( ) Cell ( ) Medications (including non-prescription) presently taking: Do you have allergies (drug, food, environmental, or other)? YES NO If yes, please explain: Do you have any dietary restrictions? YES NO If yes, please explain: MEDICAL OR HEALTH CONCERNS Please CHECK/MARK conditions/diseases you have or had. If NONE apply, check this box YES? Condition YES Condition YES Condition ADD/ADHD/ Learning Disability Epilepsy/Seizures Mobility Limitations Alcohol or Substance Abuse Eye Problems Mononucleosis Anemia or Other Blood Condition Gastrointestinal Disorder Neurologic Condition Arthritis Head Injury/Concussion/Loss of Consciousness Rheumatic Fever Asthma/Lung Disease/ Pneumonia Hearing Loss Spinal Problems/Injury Bladder/Kidney Disease Heart Disease Stroke Cancer Hepatitis Thyroid Problem Depression/Anxiety/Psychological Disorders Hernia Tuberculosis Diabetes High Blood Pressure Ulcers (Stomach/Duodenal) Ear/Nose/Throat Problems Immunocompromising Condition/HIV Vertigo/Dizziness/Fainting Eating Disorder Menstrual/Gynecologic Problems Vision Impairment Eczema/Psoriasis/Skin Disorder Migraine/Frequent/Severe Headaches Other: Surgery (specify): Fracture (specify): Chronic or long term on-going condition: List date(s) and reason(s) for any hospitalizations: Have you had severe symptoms and/or treatment for emotional or psychological problems? Describe and list current medication. Can you participate in the essential functions of your study abroad program without accommodation? Yes No If No, what type of accommodation if required? Page 1 of 5

3 TRAVEL DATES: COMPLETED BY STUDENT Date of flight leaving the U.S. Date returning to the U.S. / / / / Travel Destination(s): Routine Immunizations Vaccine Doses MM-DD-YY MM-DD-YY MM-DD-YY MM-DD-YY MM-DD-YY POLIO (IPV: 4 doses recommended by age 6) Or (OPV: 5 doses recommended by age 6) DIPHTHERIA-PERTUSSIS Tetanus (DTaP/Baby Shots) 5 Doses by age 6 TETANUS - DIPHTHERIA (DT) or (Td) Booster every 10 years 3. MEASLES (Rubeola) 2 doses RUBELLA (German Measles) 1 dose on or after 1 st birthday IMMUNIZATION RECORD and EVALUATION: COMPLETED BY MEDICAL PROVIDER MUMPS 1 dose on or after 1 st birthday MMR (Measles, Mumps, Rubella) If given instead of individual immunizations HEPATITIS A (Optional) HEPATITIS B (Optional) MENINGOCOCCAL (Meningitis) or Measles Serology: Date: Titer: 1. or Rubella Serology: Date Titer: 1. or Mumps Diagnosed by Physician Date: VARICELLA (Chickenpox) Or Chickenpox diagnosed by Physician Date: PPD - TUBERCULOSIS SKIN TEST Date Read mm Induration Recommended Travel Vaccines After reviewing vaccinations recommended or required by the Centers for Disease Control for the study abroad destination(s), please indicate any travel vaccinations given below. This may include, but is not limited to, Japanese encephalitis, Malaria prophylaxis, Rabies, Typhoid fever, Yellow fever, etc. Vaccine MM-DD-YY Comments Page 2 of 5

4 PHYSICAL EXAM: COMPLETED BY MEDICAL PROVIDER Height: Weight: Blood Pressure: Pulse: EVALUATION OF SYSTEMS System Normal findings? Description of Abnormalities HEENT Yes No Respiratory Yes No Cardiovascular Yes No Gastrointestinal Yes No Endocrine Yes No Musculoskeletal Yes No Integumentary Yes No Renal/Urinary Yes No Lymphatic Yes No Nervous System Yes No Does this student have any history of allergy, anaphylaxis, or asthma? If yes, please explain: Is the student currently undergoing treatment for any medical condition? If yes, please explain: Does the student have any physical limitations that we should be aware of? If yes, please explain: Yes Yes Yes No No No Are you aware of any history of psychological disorders (i.e. depression, anxiety, eating disorders, etc.)? If yes, please explain: Yes No Please include any additional information that you deem necessary in your assessment of the student s physical health. Page 3 of 5

5 MEDICAL CARE PROVIDER CLEARANCE: COMPLETED BY MEDICAL PROVIDER I have thoroughly reviewed the student s health, referring to the student s health history provided on this forms, and medical records on file. Based on this information, as well as my current observation of this student, to the best of my knowledge: (Initial one box below) Student is CLEARED. I have reviewed the patient s medical history. There are no medical or mental health contraindications to participation in this study abroad program. I have discussed with the student all vaccinations recommended by the Centers for Disease Control for his/her travel destination(s). Student is NOT CLEARED. There are medical or mental health contraindications to participation in the study abroad program that the student has chosen. Student is CLEARED with additional considerations. I have reviewed the student s medical history. I have discussed with the student all vaccinations recommended by the Centers for Disease Control for his/her travel destination(s). Additional considerations explained below. Student requires an accommodation or support to assist in his/her medical/psychological conditions in order to participate in the study abroad program. Indicate and describe the treatment plan in place and comment on the student s stability. Printed Name: Signature: Medical Degree: DATE: / / Office Contact Information: Address: Phone Number: Fax Number: Page 4 of 5

6 STUDENT ACKNOWLEDGEMENTS: COMPLETED BY STUDENT Please read each section carefully and sign below. I. ACCURACY OF INFORMATION CONTAINED HEREIN I hereby verify that all the information contained in this form is accurate and acknowledge that failure to provide accurate information may result in my dismissal from the program. II. III. IV. EMERGENCY CARE WHILE ABROAD I hereby consent to medical personnel designated or authorized by the Gonzaga University or administrator(s), in case of a medical emergency involving myself while attending the program to perform upon or administer any necessary medical or surgical treatment. In addition, I must personally consent to said medical procedure if I am physically and emotionally capable of consenting at the time such treatment is required. In the event Gonzaga University is required to rely on this consent to authorize necessary medical care and treatment, I, individually and jointly, agree to pay for treatment or reimburse Gonzaga University if it has paid for the treatment. I further agree to pay any costs and attorney fees if Gonzaga University has to sue me for repayment. ACKNOWLEDGEMENT OF INTERNATIONAL AVAILABILITY FOR MEDICATIONS I am aware that particular prescription medications which I take may be or are unavailable in the country for this study abroad term. I understand that my choices include: talk to my doctor, look for an alternative medication that is available, cancel my plans before embarkation due to medical necessity with a full refund, look for a different study abroad country or program, or bring my choice of medication with me. If I choose to take medication with me, I understand that bringing on my trip any prescription medications that do not comply with local law could result in action against me by local authorities. I accept the consequences of this decision and understand that medical care is my responsibility and I will be subject to the laws of localities and countries in which I am traveling. I hereby release Gonzaga University from any responsibility for my medication decisions and acknowledge that I have acted independently in this decision. FUTURE MEDICAL PROBLEMS Should you develop significant health problems between the time you have completed this form and commencement of the program, which may influence your participation in the program, I understand it is my responsibility to notify the Study Abroad Office at Gonzaga University. A medical report should accompany this notification. V. TRAVEL VACCINATIONS While my medical provider may recommend travel immunizations, I understand it is my responsibility to obtain the necessary immunizations for travel abroad. I have reviewed the vaccinations recommended by the Centers for Disease Control for my travel destination(s) located at the following link: I acknowledge that traveling abroad without receiving all of the recommended vaccines poses a potential risk to my health. SIGNATURE: DATE: / / PROGRAM: TERM: Page 5 of 5

New Student Medical Forms

New Student Medical Forms Health & Counseling Services 502 East Boone Avenue Spokane, WA 99258-2506 509.313.4052 direct 509.313.5516 fax studenthealth@gonzaga.edu Welcome from all of us at the Gonzaga University Health & Counseling

More information

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all

More information

Department of State Academic Exchanges Participant Medical History and Examination Form

Department of State Academic Exchanges Participant Medical History and Examination Form Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet.

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet. Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE

More information

STUDENT HEALTH CENTER VILLANOVA UNIVERSITY CHECK LIST

STUDENT HEALTH CENTER VILLANOVA UNIVERSITY CHECK LIST CHECK LIST This health record must be COMPLETELY filled out and submitted to the Student Health Center by July 2nd. All students must submit a copy of this health record to the Student Health Center even

More information

Division of Student Affairs Department of Student Health Services

Division of Student Affairs Department of Student Health Services Division of Student Affairs Department of Student Health Services Pre Entrance Health Record Please Complete in Ink or Type Only, Faxes or Copies will not be accepted. Deadline for Submission Return To:

More information

Gaston College Health Education Division Student Medical Form

Gaston College Health Education Division Student Medical Form Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy

More information

Health Form Instructions

Health Form Instructions Health Form Instructions 888 272-7881 Fax 802 258-3509 studyabroad@sit.edu www.sit.edu/studyabroad The Health Form must be submitted within TWO WEEKS of offer of admission. If this is not possible, then

More information

Wabash Student Health Center

Wabash Student Health Center Wabash Student Health Center Information and Instructions for Completing the Student Health Record Dear Incoming Wabash Student and Parent(s): Welcome to Wabash College! In order to make your experience

More information

1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office)

1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) 1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) Dear FAMILY NURSE PRACTITIONER Student: Congratulations! As Nurse Manager of the Wellness Center I would like to welcome you

More information

MEDICAL CLEARANCE FORM CHECKLIST

MEDICAL CLEARANCE FORM CHECKLIST Office of Study Abroad 720 Northern Blvd Brookville, NY 11548 (516) 299-2508 patricia.seaman@liu.edu MEDICAL CLEARANCE FORM CHECKLIST Read all requirements and instructions carefully. MEDICAL HEALTH HISTORY

More information

Dear Incoming Student:

Dear Incoming Student: FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,

More information

FLORIDA MEMORIAL UNIVERSITY Student Health Services

FLORIDA MEMORIAL UNIVERSITY Student Health Services 1 FLORIDA MEMORIAL UNIVERSITY Student Health Services STATEMENT OF HEALTH INSURANCE COVERAGE FORM Date Due: Office of Student Affairs Miami Gardens, FL 33054 Phone 305-626-3120 Fax 305-626-3715 Florida

More information

Hinds Community College Nursing and Allied Health Programs Health Record Packet

Hinds Community College Nursing and Allied Health Programs Health Record Packet Health Record Packet All Clinical Requirements (including the NAH Health Record Packet) must be submitted by the health profession program s designated date. For students admitted to a new program, failure

More information

English Language Fellow Program Health Verification Form

English Language Fellow Program Health Verification Form English Language Fellow Program Health Verification Form You are receiving this Health Verification Form (HVF) because your application was reviewed and determined to be eligible for consideration for

More information

STUDENT HEALTH REQUIREMENTS

STUDENT HEALTH REQUIREMENTS STUDENT HEALTH REQUIREMENTS All students who are accepted at The Christ College of Nursing and Health Sciences are required to complete a health screening and provide documented immunity to specific diseases

More information

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department

More information

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY Purpose: Completion of this packet is requested as part of the admissions process. The information you provide

More information

Nurse Aide. Clinicals ** April 25 April 27, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M.

Nurse Aide. Clinicals ** April 25 April 27, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M. Nurse Aide January 11, 2016 February 11, 2016 5:00-9:00 P.M., Monday-Thursday Clinicals ** February 15 17, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M. March 21, 2016 April 21, 2016 5:00-9:00 P.M.,

More information

HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS

HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS Student: Last name: First Name: Middle Initial: Period of intended study abroad: Year(s): Fall Spring Academic Year Country Foreign Institution or

More information

Southwestern College Nursing & Health Occupations Programs

Southwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM TO THE PHYSICIAN: Southwestern College requires a physical examination for students enrolling in the Nursing and Health Occupations Programs. A statement of your knowledge of this

More information

ELK CREEK RANCH - HEALTH RECORD PO Box 1476, Cody, WY

ELK CREEK RANCH - HEALTH RECORD PO Box 1476, Cody, WY Please attach a copy of your insurance card. ELK CREEK RANCH - HEALTH RECORD Rancher!s Name Date of Birth Parent or Guardian Work Family Physician Name of individual who may take responsibility in the

More information

HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE

HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE All undergraduate students entering clinical courses are required

More information

2015 Medical Requirement Forms

2015 Medical Requirement Forms PLEASE RETAIN A COPY OF THE COMPLETED HEALTH FORMS FOR YOUR OWN RECORDS 2015 Medical Requirement Forms Ontario Public Health regulations and St. Clair College Policy require health screening for all persons

More information

American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level.

American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level. American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level. Place Photo Here Member Information Member Name: Troop #: Date

More information

Trinitas School of Nursing Health Clearance Information

Trinitas School of Nursing Health Clearance Information Trinitas School of Nursing Health Clearance Information Students are required to have health clearance before they are allowed to register for NURE 131 and higher courses. All NURE 132, NURE 231, NURE

More information

HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES

HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES Medical clearance is mandatory in order to see any patient in the clinical setting. As there is patient contact in the didactic year, clearance

More information

Emergency Medical Technician

Emergency Medical Technician Emergency Medical Technician Admission Requirements EMERGENCY MEDICAL TECHNICAL IMPORTANT: PLEASE READ CAREFULLY Classes are held on Tuesday and Thursday nights from 5:00 p.m. until 9:00 p.m. All classes

More information

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires

More information

University of Hawai i at Mānoa University Health Services Mānoa 1710 East-West Road, Honolulu, Hawai i 96822 (808) 956-8965 FAX: (808) 956-3583

University of Hawai i at Mānoa University Health Services Mānoa 1710 East-West Road, Honolulu, Hawai i 96822 (808) 956-8965 FAX: (808) 956-3583 University of Hawai i at Mānoa 1710 East-West Road, Honolulu, Hawai i 96822 (808) 956-8965 FAX: (808) 956-3583 Dear Entering Students: Welcome to University of Hawai i at Mānoa! The (UHSM) is located on

More information

Student Medical Form for North Carolina Community College System Institutions

Student Medical Form for North Carolina Community College System Institutions Student Medical Form for North Carolina Community College System Institutions GUIDELINES FOR COMPLETING IMMUNIZATION RECORD IMPORTANT The immunization requirements must be met; or according to NC law,

More information

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your

More information

La Salle University Initial Health and Immunization Form Page - 1

La Salle University Initial Health and Immunization Form Page - 1 La Salle University Initial Health and Immunization Form Page - 1 Attention Before your account can be created for the Health and Immunization Tracking System (hereafter called ITS ), you must have previously

More information

Gaston College Health and Human Services Division Student Medical Form

Gaston College Health and Human Services Division Student Medical Form Student Name: : Gaston College Health and Human Services Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Technician and Dietary Manager Health and Fitness Science Medical Assisting

More information

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 HEALTH REQUIREMENTS M e d i c a l Assistant Certificate (

More information

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health

More information

School of Health Sciences. WSSU Division of Nursing. Accelerated Baccalaureate of Science in Nursing (ABSN) Option

School of Health Sciences. WSSU Division of Nursing. Accelerated Baccalaureate of Science in Nursing (ABSN) Option School of Health Sciences Division of Nursing Accelerated Baccalaureate of Science in Nursing (ABSN) Option Thank you for showing interest in the ABSN option at Winston-Salem State University (WSSU). Below

More information

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner or Physician s Assistant for your physical examination.

More information

RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET

RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET School of Nursing-Camden Rutgers, The State University of New Jersey Residence Hall 215 North 3 rd Street Camden, NJ 08102-1405 nursing.camden.rutgers.edu nursecam@camden.rutgers.edu Phone: 856-225-6226

More information

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION: PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE

More information

Application Form. Global Green MBA

Application Form. Global Green MBA Faculty of Management The International School Application Form Global Green MBA Instructions All of the following materials must be submitted before your application will be processed: Application Form

More information

APPLICATION FOR THE RN to BSN PROGRAM NAME: ADDRESS:

APPLICATION FOR THE RN to BSN PROGRAM NAME: ADDRESS: APPLICATION FOR THE RN to BSN PROGRAM PLEASE PRINT CLEARLY NAME: ADDRESS: Please check Campus you wish to attend: Rutgers Camden: Atlantic Cape Community College: Camden County College at Blackwood: Home

More information

Dear Prospective Certified Nursing Assistant Student:

Dear Prospective Certified Nursing Assistant Student: Dear Prospective Student: We are pleased to welcome you to Alvin Community College and look forward to assisting you in starting your career goals in healthcare. As a, you will have many doors of opportunity

More information

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003) SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty

More information

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

More information

The Immunization Office, located in the Student Health Center, is open year round to administer needed immunizations at a nominal fee.

The Immunization Office, located in the Student Health Center, is open year round to administer needed immunizations at a nominal fee. Student Health Services 2815 Cates Avenue Raleigh, NC 27695-7304 919-515-2563 healthcenter.ncsu.edu The Immunization Record Form is designed to collect information about your current immunization status.

More information

Cumberland County College RADIOGRAPHY PROGRAM Medical History Information

Cumberland County College RADIOGRAPHY PROGRAM Medical History Information P R I D E S E R V I C E E X C E L L E N C E Cumberland County College RADIOGRAPHY PROGRAM Medical History Information Return to: Radiography Department Cumberland County College P.O. Box 1500, College

More information

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.

More information

PRE-EMPLOYMENT HISTORY AND PHYSICAL

PRE-EMPLOYMENT HISTORY AND PHYSICAL MIDWESTERN UNIVERSITY OPTI - AZCOM PRE-EMPLOYMENT HISTORY AND PHYSICAL Name Department Birth Date Age Position MEDICAL HISTORY Childhood Illnesses & Immunizations Please check the following childhood diseases

More information

LEHMAN COLLEGE DEPARTMENT OF NURSING ANNUAL HEALTH CLEARANCE REQUIREMENTS

LEHMAN COLLEGE DEPARTMENT OF NURSING ANNUAL HEALTH CLEARANCE REQUIREMENTS ANNUAL HEALTH CLEARANCE REQUIREMENTS Each student in the Department of Nursing must have current health clearance prior to each clinical nursing course (NUR 301, 303, 304, 400, 405, 409). Health clearance

More information

NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions

NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions Revised 2 REPORT OF MEDICAL HISTORY (Please print PAGE in black 2 BLANK ink) FOR INDIVIDUAL To be completed

More information

HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM

HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM Revised 3/05 HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM The class meets on Tuesday, Wednesday and Thursday from 12:00 p.m. until 6:00 p.m. The classes

More information

Student Medical Form for North Carolina Community College System Institutions

Student Medical Form for North Carolina Community College System Institutions Student Medical Form for North Carolina Community College System Institutions Revised 2 PAGE 2 Roanoke-Chowan Community College Associate Degree Nursing Student Health Form Instructions: This form must

More information

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( )

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( ) C.T. Cross Training Program Name Home Phone ( ) Address Work Phone ( ) City St. Zip E-mail NYS. License # Expiration Date Years of Experience Name of Employer Please indicate how you intend to complete

More information

HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS

HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS COMPLETION AND RETURN OF THIS FORM TO THE CAMP DIRECTORS IS REQUIRED FOR ADMISSION TO CAMP. Either Mail This Completed Form

More information

Application Form. Executive MBA

Application Form. Executive MBA Department of Business Administration The International School Application Form Executive MBA Instructions All of the following materials must be submitted before your application will be processed: Application

More information

Yong Loo Lin School of Medicine Medical Examination Report Elective Students (Local and International)

Yong Loo Lin School of Medicine Medical Examination Report Elective Students (Local and International) Yong Loo Lin School of Medicine Medical Examination Report Elective Students (Local and International) PART I (To be completed by Student) Personal Particulars: Full Name: Application No: Course of Study:

More information

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM Branch: North Brooklyn YMCA Camp Site: North Brooklyn Branch Camp Type: PARTICIPANT INFO Child s Name Age D.O.B. Gender Grade in September 2016 School

More information

Maryland Vision Institute

Maryland Vision Institute Maryland Vision Institute Any information we already have is displayed. Please review and complete all to ensure that the information we have is correct and current. Patient Info: Date Record Printed:

More information

Holy Family University, Student Health Services, Directions for Completion of Health Packet

Holy Family University, Student Health Services, Directions for Completion of Health Packet 1 Holy Family University, Student Health Services, Directions for Completion of Health Packet All forms are to be returned to Health Services by Summer Orientation for the Fall Semester and the first day

More information

Clinical/Field Pre-Placement Health Form

Clinical/Field Pre-Placement Health Form Clinical/Field Pre-Placement Health Form Program Name: Developmental Service Worker (Fast Track) Program Year: Year 1 Due Date: December following September start Program Code (#): DSW4 Program Descriptor:

More information

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

PELED PLASTIC SURGERY HEADACHE HISTORY FORM HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

More information

Medical History (to be completed by student)

Medical History (to be completed by student) Medical History (to be completed by student) Please complete this form before going to your health care professional for examination. This information is strictly for the use of the Student Health Center

More information

Student Health Forms

Student Health Forms Student Health Forms Graduate Program Important: This packet includes a comprehensive set of forms required by NYS Health law. These forms are required in order to register for classes. Please review each

More information

Medical Forms and Information Perú. The Medical Forms included in this document must be completed and returned to us no later than: June 1, 2015

Medical Forms and Information Perú. The Medical Forms included in this document must be completed and returned to us no later than: June 1, 2015 2015 Medical Forms and Information Perú The Medical Forms included in this document must be completed and returned to us no later than: June 1, 2015 1 Vaccinations & Medication The locations for STRIVE

More information

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM NURSING PROGRAM

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM NURSING PROGRAM HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM NURSING PROGRAM Purpose: Completion of this packet is requested as part of the admissions process. The information you provide will be evaluated

More information

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements:

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements: Certified Nurse Aide (CNA) - Student Requirements: STAFF VERIFICATION: DATE: COMMENTS: Desired Class Date: _ Session: CEQ Name: Address: City:, Texas Zip: Phone #: Alt #: Email: Students entering the Certified

More information

Harrison Central School District Harrison, New York

Harrison Central School District Harrison, New York Harrison Central School District Harrison, New York Dear Parents and Guardians of Returning Students: Attached are health forms to be completed by you and your pediatrician and returned to the school nurse.

More information

Physical Examination: A licensed Physician, Nurse Practitioner or Physician s Assistant must complete and sign the Physical Examination form.

Physical Examination: A licensed Physician, Nurse Practitioner or Physician s Assistant must complete and sign the Physical Examination form. Health Services Welcome to Austin College! These forms are both required and time-sensitive. Failure to complete the required information could affect your ability to move into your residence hall, participate

More information

Emory Eye Center New Patient Questionnaire

Emory Eye Center New Patient Questionnaire Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

More information

Plan early - get your vaccinations in time for full protection. To prepare for your trip, schedule an appointment: (910) 347-2154, option #2.

Plan early - get your vaccinations in time for full protection. To prepare for your trip, schedule an appointment: (910) 347-2154, option #2. The Onslow County Health Department Travel Clinic offers a complete line of immunizations and prescriptions to protect you while traveling abroad. The most appropriate immunizations and travel medications

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

More information

SALVE REGINA UNIVERSITY HEALTH FORM

SALVE REGINA UNIVERSITY HEALTH FORM SALVE REGINA UNIVERSITY HEALTH FORM 100 Ochre Point Avenue Newport, Rhode Island 02840-4129 phone: 401-341-2904 fax: 401-341-2934 email: healthservices@salve.edu COMPLETED FORMS DUE BACK TO THE HEALTH

More information

Entrance Health Certificate

Entrance Health Certificate Entrance Health Certificate 1 Wheelock College Student Health Service ENTRANCE HEALTH CERTIFICATE The Entrance Health Certificate must be completed in its entirety and brought with you to Boston. Admission

More information

PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider

PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider All full-time, undergraduate students must have a physical exam. PERSONAL DATA Name: Last First Middle Birthdate: Height: Weight:

More information

RE: Youth Challenge International Medical Form. Dear Doctor:

RE: Youth Challenge International Medical Form. Dear Doctor: RE: Youth Challenge International Medical Form Dear Doctor: Thank you for helping to prepare this candidate for an overseas volunteer project with Youth Challenge International in a developing country.

More information

Delaware County Community College Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements

Delaware County Community College Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements ******All Forms Due by the First Monday in July***** Program Requirements Matriculation into the Nursing Program and most

More information

COLUMBUS STATE COMMUNITY COLLEGE Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program

COLUMBUS STATE COMMUNITY COLLEGE Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program 1 Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program HEALTH HISTY To be completed by the Student: PLEASE PRINT ALL INFMATION COUGAR I.D. Name: SS#: Last

More information

Immunizations Frequently Asked Questions

Immunizations Frequently Asked Questions Student Health Services 6410 Fannin St Suite 130 Houston, TX 77030 713 500 5171 tel Immunizations Frequently Asked Questions Campus Solutions Immunizations Questions: 1. What is the Campus Solutions Immunizations

More information

Florida Eye Center Patient Registration Form (Please Print Clearly)

Florida Eye Center Patient Registration Form (Please Print Clearly) Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address:

More information

Health Center Requirements Academy by the Sea/Camp Pacific

Health Center Requirements Academy by the Sea/Camp Pacific Health Center Requirements Academy by the Sea/Camp Pacific The information in this health packet is used to assist our health care professionals in providing proper care for your child. In an effort to

More information

CAMP ECOVENTURE REGISTRATION FORM. Camper s Name LAST FIRST MI. Home Address

CAMP ECOVENTURE REGISTRATION FORM. Camper s Name LAST FIRST MI. Home Address CAMP ECOVENTURE REGISTRATION FORM SECTION I BASIC CONTACT INFORMATION Camper s Name LAST FIRST MI Birth Date / / Age Gender Male Female Grade entering this coming September Camper attended EcoVenture last

More information

PD:lt Patient Care. Education. Research. Community Service An Affirmative action/equal opportunity institution

PD:lt Patient Care. Education. Research. Community Service An Affirmative action/equal opportunity institution University Health Services University of Cincinnati PO Box 670460 Cincinnati OH 45267-0460 Holmes Building Phone (513) 584-4457 Fax (513) 584-2222 Date: April 15, 2015 TO: All Matriculating Pharmacy Students

More information

All Nursing Students. Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only)

All Nursing Students. Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only) To: Subject: All Nursing Students Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only) All nursing students must meet the following criteria

More information

Integrated Medical Services (IMS) New Patient Registration Sheet

Integrated Medical Services (IMS) New Patient Registration Sheet Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:

More information

Insured Party Information (please complete if the insurance is not in your name)

Insured Party Information (please complete if the insurance is not in your name) Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr

More information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH

More information

CNA Certified Nurse Assistant Program

CNA Certified Nurse Assistant Program Health Center Signature/Stamp *1 st floor of Student Services Building HEALTH SCIENCES PROGRAM HEALTH REQUIREMENTS To be filled out by Health Care Provider (HCP) CNA Certified Nurse Assistant Program Student

More information

HARRISON CENTRAL SCHOOL DISTRICT 50 Union Avenue Harrison, New York (914) 835-3300

HARRISON CENTRAL SCHOOL DISTRICT 50 Union Avenue Harrison, New York (914) 835-3300 HARRISON CENTRAL SCHOOL DISTRICT Harrison, New York (914) 835-3300 Dear Parents and Guardians of New Entrants: Welcome to the Harrison Central School District. Attached are health forms to be completed

More information

Immunization Forms. In lieu of these forms you may submit the following:

Immunization Forms. In lieu of these forms you may submit the following: Immunization Forms Welcome to Clemson University! We are glad you have chosen us to meet your higher education goals. The University requires a complete immunization record to be on file at for all students.

More information

Student Medical Form for North Carolina Community College System Institutions

Student Medical Form for North Carolina Community College System Institutions Student Medical Form for North Carolina Community College System Institutions Name Program Revised 2 Student Medical Form For Programs that Require Health Forms NURSING AND ALLIED HEALTH Name Program of

More information

We offer two schedules for our RN Refresher program:

We offer two schedules for our RN Refresher program: Dear Prospective Student, Thank you for your interest. Attached you will find an application to participate in an innovative R.N. Refresher course sponsored jointly by Molloy College Continuing Education

More information

Greetings from Oklahoma Wesleyan University Student Health Services! STUDENT HEALTH OFFICE AND MEDICAL ATTENTION MEDICAL FORMS PHYSICAL EXAMS

Greetings from Oklahoma Wesleyan University Student Health Services! STUDENT HEALTH OFFICE AND MEDICAL ATTENTION MEDICAL FORMS PHYSICAL EXAMS Return all medical forms to: Student Health Department Oklahoma Wesleyan University 2201 Silver Lake Road Bartlesville, OK 74006 Greetings from Oklahoma Wesleyan University Student Health Services! My

More information

ACC Nurse Refresher Course Continuing Education Department

ACC Nurse Refresher Course Continuing Education Department ACC Nurse Refresher Course Continuing Education Department Alvin Community College 3110 Mustang Road Alvin, TX 77511 Ph: 281-756-3796 Fax: 281-756-3952 Dear Prospective Nursing Refresher Student, Alvin

More information

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Age: Date: Address: Telephone Number: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)

More information

WELCOME PATIENT CONDITION

WELCOME PATIENT CONDITION NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer

More information

Providence Alliance for Catholic Teachers (PACT)

Providence Alliance for Catholic Teachers (PACT) Providence Alliance for Catholic Teachers (PACT) Health and Wellness History Please place this form in a separate sealed envelope, marked with your name and Health and Wellness History. Submit to PACT

More information

Health Information Form for Adults

Health Information Form for Adults A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home

More information

DEADLINE DATES: Summer 2013 Enrollment: Apr. 29, 2013 Fall 2013 Enrollment: Jul. 16, 2013 Spring 2014 Enrollment: Dec. 17, 2013

DEADLINE DATES: Summer 2013 Enrollment: Apr. 29, 2013 Fall 2013 Enrollment: Jul. 16, 2013 Spring 2014 Enrollment: Dec. 17, 2013 DEADLINE DATES: Summer 2013 Enrollment: Apr. 29, 2013 Fall 2013 Enrollment: Jul. 16, 2013 Spring 2014 Enrollment: Dec. 17, 2013 Dear Student, Welcome to Columbia University Medical Center (CUMC). Here

More information